Online Video Tele Consultation - Nutrition Assessment

Personal Information

First name or Initial *

Last name

Date of Birth

(or) Age *

Gender *
Male Female Other

Occupation

Email *

Query

Body Measurements

Please fill in details only if you are comfortable with sharing them for the consultation

Unit Type *

Metric (kg & cm) US (Pounds & Feet)

Height (cm) *

(or) Feet

Inches

Current Weight (kg) *

BMI

Weight, 1 yr ago (kg)

Lowest adult weight (kg)

Highest adult weight (kg)

Desired weight (kg)

Waist (cm) *

Hip (cm) *

Wrist (cm)

Neck (cm)

Does your weight affect the way you feel about yourself?

Any goals for nutrition consultation *

Lose Weight Put on Weight Other

(kg)

Do you follow a particular diet/eating pattern? *

Yes No

Diet/eating pattern *

Vegan (Plant based and no dairy products)

Vegetarian

Non-vegetarian

Previous dietitian consultations? *

Yes No

5:2 Diet

Intermittent Fasting

Mediterranean Diet

Ketogenic Diet

Veganism

Carnivore Diet

Paleo Diet

Sirtfood Diet

Atkins diet

Zone diet

Vegetarian diet

Vegan diet

Weight Watchers diet

South Beach diet

Raw food diet

Blood Type Diet

Cabbage oup Diet

Grapefruit Diet

Beverely Hills Diet

DASH diet

Diabetic Diet

Gluten Free diet

Kidney diet

Liquid diet

Comments

Medical History

Current Medical History

No significant history

Abdominal Pain

Alcohol Addiction and Women

Anemia

Anxiety Disorder

Asthma

Autoimmune Disorders

Binge Eating Disorder

Breast Feeding

Cholesterol

Chronic Obstructive Pulmonary Disease

Constipation

Depression

Diabetes

Diabetic Kidney Disease

Female Sexual Dysfunction

GERD

Hair Loss

Headache / Cephalgia

Heart Attack

Heartburn Symptom Evaluation

High Blood Pressure

Indigestion

Infertility

Iodine Deficiency Disorder

Irritable Bowel Syndrome

Lactose Intolerance

Menopause

Obstructive Sleep Apnea

Osteoporosis

Peptic Ulcer

Polycystic Ovarian Syndrome

Pregnancy

Premenstrual Syndrome

Sleep Disorder

Types of Food Allergies

Ulcerative Colitis

Abdominal Distension

Abortion

Acne

Alcoholic Liver Disease

Anemia in Pregnancy

Aplastic Anemia

Attention Deficit Hyperactivity Disorder (ADHD)

Bleeding Disorders

Breast Cancer

Carbohydrates and Weight Loss

Chest Pain

Chicken Pox

Chronic Fatigue Syndrome

Crohns Disease

Deep Vein Thrombosis

Deep Vein Thrombosis and Flying

Diabetes and Hypertension

Fatty Liver Disease: A Growing Health Problem in India

Fever

Gallstones

Gestational diabetes

Health Screening for Men between 40 and 64 years of Age

Kidney Stones

Leucopenia / Leukopenia

Leukemia

Metabolic Syndrome

Migraine

Miscarriage

Morning Sickness

Nausea and Vomiting

Portal Hypertension

Respiratory Diseases

Rheumatoid Arthritis

Sickle Cell Anemia

Skin Disease

Sleep

Sleep Disturbances In Women

Sleep Eating Disorders

Stroke

Tuberculosis

Type 2 Diabetes

Urinary Tract Infection

Past Medical History

No significant history

Abdominal Pain

Alcohol Addiction and Women

Anemia

Anxiety Disorder

Asthma

Autoimmune Disorders

Binge Eating Disorder

Breast Feeding

Cholesterol

Chronic Obstructive Pulmonary Disease

Constipation

Depression

Diabetes

Diabetic Kidney Disease

Female Sexual Dysfunction

GERD

Hair Loss

Headache / Cephalgia

Heart Attack

Heartburn Symptom Evaluation

High Blood Pressure

Indigestion

Infertility

Iodine Deficiency Disorder

Irritable Bowel Syndrome

Lactose Intolerance

Menopause

Obstructive Sleep Apnea

Osteoporosis

Peptic Ulcer

Polycystic Ovarian Syndrome

Pregnancy

Premenstrual Syndrome

Sleep Disorder

Types of Food Allergies

Ulcerative Colitis

Abdominal Distension

Abortion

Acne

Alcoholic Liver Disease

Anemia in Pregnancy

Aplastic Anemia

Attention Deficit Hyperactivity Disorder (ADHD)

Bleeding Disorders

Breast Cancer

Carbohydrates and Weight Loss

Chest Pain

Chicken Pox

Chronic Fatigue Syndrome

Crohns Disease

Deep Vein Thrombosis

Deep Vein Thrombosis and Flying

Diabetes and Hypertension

Fatty Liver Disease: A Growing Health Problem in India

Fever

Gallstones

Gestational diabetes

Health Screening for Men between 40 and 64 years of Age

Kidney Stones

Leucopenia / Leukopenia

Leukemia

Metabolic Syndrome

Migraine

Miscarriage

Morning Sickness

Nausea and Vomiting

Portal Hypertension

Respiratory Diseases

Rheumatoid Arthritis

Sickle Cell Anemia

Skin Disease

Sleep

Sleep Disturbances In Women

Sleep Eating Disorders

Stroke

Tuberculosis

Type 2 Diabetes

Urinary Tract Infection

Personal History

Digestive Function *

Good Fair Poor

Bowel Movements *

Daily Once Daily Twice Daily more than 3 Weekly 3-4 times Weekly Once Diarrhea Constipation

Symptoms & Signs

Rate your Typical energy level *

Excellent Good Satisfactory Poor

Any recent blood tests, please mention below:

Medications/Supplements

include vitamins, minerals, herbs, medical foods, etc.

Medication / Supplement	Dosage	Frequency	Instructions

Comments

Exercise/Activity *

Yes No

Type *(eg:walking,jogging,Dancing,Swimming,Biking etc)

How often? *(eg:Regularly,Occasionaly,Rarely,Weekly etc)

How long? *(eg:30 mins)

Sleep *

8+ hours 6-8 hours <6 hours

Sleep Quality *

Good Fair Poor

Life stressors *

Work

Health

Family

Relationship/ friendships

Finances

Other

What do you do to relax? (eg:yoga,meditation, mindfulness, write journal etc)

Comments

Diet & Food Habits

Water intake per day *

Water unit *

What are your personal challenges to eating well?

Are you aware of any adverse food reactions(allergies/intolerances)? *

Yes No

How frequently do you eat out? *

Weekly Once Weekly Twice More than Twice Everyday Occasionally

Where?

Do you grocery shop? *

Yes No

Do you cook? *

Yes No

Food Log

INSTRUCTIONS

Please write down all foods and beverages consumed for three 24-hour time periods. Each day starting at 12:00 am and ending at 11:59 pm. Choose three consecutive days, including two weekdays and one weekend.
List the approximate Time the meal was consumed and the type of eating occasion or Meal (breakfast, lunch, dinner, snack, or other).
List each Food/Beverage Item you consumed, including foods eaten between meals and all drinks, even if it is a non-caloric item like water, coffee, tea, or sugar free gum.
Record the Amount of each food or beverage consumed.

Example
Food Type	Food Time	Food and Beverages	Quantity
Breakfast	8:00 am	Brown Sugar Instant, Milk, Coffee	2 packets
Lunch	12:00 pm	Pizza, Water	2 slices Size D-4 each

Added Food Log

Date

Food Type

Time

Food and Beverages

Quantity

Action

Add Food Log

Note : You can select the food items from the drop-down list, or you can simply enter them by disabling the drop-down list.

Date

Food Type

Time

Food and Beverages

Quantity

+ More Food Add